Recovery, Meds and When?

  • Recovery starts with hope, optimism, and the fundamental belief that recovery is possible.
  • There is no single pathway to recovery. It is a uniquely personal, self-determined, and self-managed journey.
  • Recovery is an ongoing journey – marked by achievements and by setbacks – that enable people to take charge of their mental health and wellbeing.

 

Recovery Declaration Cover2

Recovery Declaration

The above are the first three points in the Mental Health Commission of Canada’s Recovery Declaration (click to view pdf). It’s an excellent document (my thanks to Chris Summerville, executive director of the Manitoba Schizophrenia Society and CEO of the Schizophrenia Society of Canada, for bringing it to my attention).

The challenges of ACT at times overshadow the concepts of recovery, all the more reason for clinicians to return to these concepts again and again. At the same time putting these concepts into practice can sometimes be so very challenging.

One of the other points in the MHCC’s Recovery Principles states:

  • Recovery-oriented practices and services support the recovery journey by respecting the dignity of risk and balancing calculated risk-taking with legal obligations of care.

I think the commission has put this well – “respecting the dignity of risk and balancing calculated risk-taking. This is how I want to be treated by my health care professionals and this is how I should treat patients/clients.

At times however I wrestle with how to apply this in practice. For example consider the following:

Joe is a 47y/o single man who developed paranoid schizophrenia in his late teens. When he was 20 and while very paranoid, he had an altercation with his father and pushed father down a flight of stairs. Father suffered a significant injury. Joe and his parents have had no contact since. Joe had long hospital stays over many years until he was connected with our PACT team.

Joe has been able to live independently for a number of years with PACT support. He goes to a pharmacy near his home every day and takes his meds in front of the pharmacy staff. He still experiences paranoia on a daily basis.

Every time I meet with Joe he asks when he can stop his meds. Every time I answer “not right now.” Joe doesn’t ask “and when will that time come?” Had he done so I don’t know how I would answer; I could not honestly give him a date .

My read of the literature is that for individuals who have had multiple episodes of psychosis (almost by definition ACT clients will have had multiple episodes, otherwise they probably should utilize other, less intensive services) the risk of relapse when stopping meds is substantial – not immediately but over the months and years the stats show relapse to be common.

Does this mean I never respect and agree with a client’s decision to see how they do off meds? At times I do agree and then we’ll discuss how best to approach this, addressing such things as

  • What’s the safest – usually the smallest – dosage decrease possible and what should be the timing for further changes?
  • Do they know how to recognize their early warning signs of relapse?
  • Does their support system know about the decision and how will the client respond to feedback from them?

But if, like Joe, who’s had multiple relapses and, when ill poses a very real danger not only to himself but to those around him, that decision is a tough one, or at least a tougher one to explain to the client.

Recovery principles should not just be ideas we endorse publicly, concepts we like in the abstract. They should be part of our mindset, part of our everyday practice as ACT clinicians.

Even when the answers aren’t clear it’s worth wrestling with the questions.

I’d be interested to hear what you think based on your experience. Please post a comment.

Shalom Coodin

2 comments

  1. It may not be so difficult to do in the ACT context. Treating participants as equal is the first step in service provision. It holds both participants and workers to basic standards of life such as: well maintain living space, taking care of our body, and do things that are important to us. Taking medication is just small part of life and much bigger is having a hobby, work, or group of people we belong to. Frequently people are focusing on medication as it symbolizes for them the sentence of mental health diagnosis. That can be better addressed by helping people to do stuff they are missing because of their mental illness. Very frequently ordinary duties or thing we dream about such as job, volunteering, group activity or family visit becomes a driving force in regaining life. ACT team that “works out of importance and not out of urgency” (Shalom’s quote) focuses on this and helps people to ad one step in their recovery. You should see the excitement of over 20 participants who sign to work with company who remove the snow.

    Roman

  2. I have faced similar challenges supervising an ACT team in Florida. As a team, we try to balance the desires of the client with the safety issues that may arise when some clients want to stop their medications. With clients with severe mental illness and acute episodes of psychosis without medication, we strongly encourage clients to stay on their meds. I like the “not right now” answer, as we use a tentative approach like this often. Deferring the client to “wait and talk with the psychiatrist” before they decide to stop taking any of their meds. Ultimately it is the cilent’s choice, but we try and talk with them about what happened other times that they stopped taking there meds, as well as continued discussion about what the meds do help with when they have been taking them, as a reminder.

    -Jennifer Botelho, LMHC FACT Team

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